Eastern Association for the Surgery of Trauma: A Review of the Management of the Open Abdomen—Part 2 “Management of the Open Abdomen”

During the course of the last 30 years, several authors have contributed their clinical experience to the literature in an effort to describe the various management strategies for the appropriate use of the open abdomen technique. There remains a great degree of heterogeneity in the patient population, and the surgical techniques described. The open abdomen technique has been used in both military and civilian trauma and vascular and general surgery emergencies. Given the lack of consistent practice, the Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Committee convened a study group to establish recommendations for the use of open abdomen techniques in both trauma and nontrauma surgery. This has been a major undertaking and has been divided into two parts. The EAST practice management guidelines for the open abdomen part 1 “Damage Control” have been published.1 During the development of the open abdomen part II “Management of the Open Abdomen,” the current literature remains contentious at best, current methods of treatment continue to change rapidly, and patient populations are so heterogeneous that clear recommendations could not be provided. What follows is a thorough review of the current literature for the management of the open abdomen: part 2 “Management of the Open Abdomen” and provides clinical direction regarding the following specific topics. Early and Delayed Abdominal Fascial Closure (DAFC). Management of intestinal fistula in the setting of the open abdomen. Management of the planned ventral hernia. Process A computerized search of the National Library of Medicine Medline database was undertaken using the PubMed Entrez interface. English language citations were identified during the period of 1984 through 2009 using the primary search strategies outlined. Given the complexity of this literature, several strategies were necessary to appropriately capture the breadth of evidence on the topic. The search excluded case reports, reviews, letters/commentary, editorials, and articles focusing only on pediatric participants. The PubMed Related Articles algorithm was also used to identify additional articles similar to the items retrieved by the primary strategy, in addition to hand searching of the reference lists of key articles retrieved by the searches. Of ∼1,300 articles identified by these two techniques, only prospective or retrospective studies examining open abdominal management were selected, consisting of 79 institutional studies evaluating open abdomen management strategies in the adult surgical/critical care population. The articles were reviewed by a group of 16 surgeons who collaborated to produce this clinical review. The chair, vice chair, and three committee members (JJD, WD, MO) reviewed all the articles to categorize them into the three study topics. They were distributed to all members of the study group for critical review. Each committee member was to answer the following three questions of each article reviewed: What is the class of evidence in the article? Are the results of the article valid based on the data presented? What is your conclusion based on the evidence the article provides. Review During the development of this review, a common language for the closure of the open abdomen was developed, which is provided in Table 1. Figure 1 is a proposed flow diagram for the closure of the open abdomen in trauma, emergency general, and vascular surgery.TABLE 1: Definition of Abdominal Closures and Planned Ventral Hernia: Trauma, Emergency General, and Vascular SurgeryFigure 1.: The closure of the open abdomen in trauma, emergency general, and vascular surgery flow diagram.Early Abdominal Fascial Closure Timing Trauma surgeons have gained an immense amount of experience with multiple techniques used to achieve abdominal closure of the open abdomen, but questions still remain. How long can the abdomen remain open? When does the risk of complications begin to increase? Is there a specific technique that is better than the rest for closing the open abdomen? At what point should all attempts at delayed fascial closure be abandoned and a planned ventral hernia performed? Miller et al.,2 in a study of 344 damage control laparotomies demonstrated that early abdominal fascial closure can be achieved in the majority (63%) of damage control cases during the initial re-laparotomy. They showed that DAFC before 8 days was associated with fewer complications: 12% in those closed before 8 days and 52% closed after 8 days. Yet, in a study of trauma patients with an open abdomen, massive visceral edema, and loss of domain, fascial closure could be achieved using the V.A.C. therapy (vacuum-assisted closure, KCI, San Antonio, TX) overtime out to a 4-week period with acceptable complication rates.3 With this degree of variation in timing to closure and the dreaded risk of life threatening complications more data were needed. Delayed Abdominal Fascial Closure Techniques (Nontraumatic/Traumatic Fascial Closure) Multiple studies have shown that DAFC is safe and effective at achieving successful fascial closure in 65% to 100% of patients with an open abdomen.2,4–25 There is evidence that vacuum-assisted closure devices (VACD) facilitate delayed primary fascial closure with high success rates and low morbidity.3–5,7,13,14,16–18,26 The literature describes both commercially available devices (V.A.C. therapy) as well as “home make” noncommercial “vacuum packed–negative pressure dressing” devices as being helpful in achieving DAFC (Table 2).TABLE 2: Delayed Abdominal Fascial ClosureTABLE 2: Delayed Abdominal Fascial Closure (continued)In the setting of intra-abdominal sepsis, the effectiveness of VACD to achieve DAFC has not been as successful as the experience seen in trauma patients.27 Wondberg et al.28 studied 30 patients with intra-abdominal sepsis and an open abdomen. They showed that only 33% of the study group was able to achieve DAFC with the use of the V.A.C. therapy KCI. Failure to achieve DAFC is associated with significant financial cost, increased morbidity including wound infections and the formation of intestinal fistula.29–31 Although, studies have shown that using VACD in conjunction with dynamic serial fascial advancement, can achieve fascial closure with success rates of 86% to 100% in trauma patients.4,7,18,32 The Wittmann Patch (Starsurgical, Burlington, WI), an “artificial burr” Velcro-like device that is sutured to the abdominal fascia, when used to manage an open abdomen has been shown to facilitates DAFC with a success rate >80% in a group of mixed trauma and abdominal sepsis patients.10,23 The Wittmann Patch can be used as a successful tool to provide dynamic tension in a process toward fascial closure.28,29 Similar to the Wittmann Patch, the use of temporary prosthetic mesh (most commonly polytetrafluoroethylene) with serial tightening/pleating has resulted in fascial closure rates from 89% to 100%.14–21 Serial/dynamic suture tightening, a technique involving repeated partial closure of the fascia, has also been used to achieve DAFC at rates between 61% and 90%.6,12,15Table 3 describes the most commonly used abdominal closure surgical techniques and the differences between them.TABLE 3: Definitive Abdominal Fascial Closure of the Open AbdomenThere is one randomized prospective study comparing various techniques for DAFC. Bee et al.33 compared the use of a VACD versus using a temporary polyglactin mesh and showed no difference in the rate of DAFC (31% vs. 26%). However, the success rates of DAFC in this study are significantly lower than other published studies, making the results difficult to interpret. Fascial Bridge Closure It has been previously described, a patient with an open abdomen can undergo multiple re-operations with progressive closure of the fascial defect, with or without the use of a VADC, and have their fascial defect closed.3 In the setting of ongoing intra-abdominal infection or the formation of an enterocutaneous fistula abdominal fascial closure is often not possible.19 Fascial closure may not be possible because of ongoing visceral edema with loss of abdominal domain or from loss of fascia from infection. At this point, a fascial bridge closure of the resulting abdominal fascial defect may be considered. The abdominal viscera will become cocoon in the 14-day period to 21-day period. Attempting re-enter into the abdomen cavity to free the visceral off the abdominal wall to allow for an easier abdominal fascial closure is both difficult and dangerous. The surgeon is limited in the available surgical options: (1) bridge repair of the fascial defect using a mesh to create a bridge closure, (2) performing an acute abdominal wall reconstruction using most commonly a version of component separation, or (3) a planned ventral hernia. Fansler et al.34 reported their experience with the fascial bridge closure of the open abdomen with permanent prosthetic mesh. In a series of combined trauma and abdominal sepsis patients, polypropylene was used as a fascial bridge for early definitive closure. They had significant complications including a 50% enterocutaneous fistula rate, which were noted with the use of polypropylene mesh. Voyles et al.35 reported a similar experience with a high rate of complications and fistula formation. The association of synthetic prosthetic mesh with bacterial colonization is well known. Once colonized or infected, the prosthetic mesh acts as a chronic source of contamination.27,33,36 The use of permanent prosthetic mesh such as polypropylene, polytetrafluoroethylene, and polyester products has been abandoned in these circumstances because of the high rates of complications seen with their use. Biological mesh material has been commercially available for almost 10 years. Biological mesh originates from human donors, bovine, and porcine animals. Biological mesh has been successfully used to bridge the defect as a result of an open abdomen. Human acellular dermal matrix (HADM) (AlloDerm, LifeCell Corp.) has been shown to be successfully used as a fascial bridge after open abdomen in multiple studies.19,37–39 HADM does not seem to form significant adhesions, seems to tolerate bacterial contamination, and does not require removal in the setting of infection.19,37,38,40–42 Also, HADM has been successfully used for tissue coverage and closure of large traumatic wounds in the setting of significant skin and soft tissue loss.32 Once the HADM has developed a good granulated tissue base, a skin graft can be placed. The authors noted that when no soft-tissue coverage is available, keeping the graft moist is critical to the graft's survival. Moist saline dressings or KCI V.A.C. therapy are most often used for this purpose. Bacterial colonization with overgrowth can occur on the grafts. This has been reported in the early postoperative phase and before the graft has had time to revascularize. The use of silver sulfadiazine or sulfamylon-soaked dressings on the graft should decrease bacterial counts until vascular in-growth has occurred and may prevent early graft loss from infection. The long-term success of using HADM as a fascial bridge for hernia repair after an open abdomen technique is unclear. There are a number of studies suggesting that the long-term strength of the HADM decreases overtime. This multifactorial may be attributable to collagen re-modeling, mesh attenuation, or tissue growth resulting in a high rate of hernia formation.43,44 However, HADM bridge ventral hernia repairs have been performed after trauma and many patients have had definitive repairs.16 Singh et al.,38 report on 10 liver transplant patients treated with an open abdomen and closed with an HADM fascial bridge. In short-term follow-up (10 months), there were no cases of herniation noted. Conversely, de Moya et al.,45 demonstrated that patients treated with an HADM bridge repairs and that at 1-year follow-up had evidence of recurrent hernia or significant abdominal wall laxity. The use of HADM as a fascial bridge under the circumstances of the unclosable abdomen after damage control is supported by the available literature. It protects the viscera from fistulization and may provide definitive abdominal wall strength. Yet, the long-term results in providing definitive fascial strength are not known. Acute Component Separation One option for closure of the open abdomen is an acute abdominal wall reconstruction using the component separation techniques. Ramirez et al.,46 were the first to describe the component separation technique for reconstruction of large abdominal wall fascial defect without the use of prosthetic mesh. In its basic form, the technique is as follows: (1) the anterior abdominal wall skin flaps are developed and dissected out to the anterior superior iliac spine and the chest wall, (2) the aponeurosis of the external oblique muscle is divided lateral to the semilunar line on to the chest wall to the level of the xiphoid, (3) free up the external oblique, which will allow the rectus myofascial component to be mobilized medially, and (4) the midline is sutured together. The component separation has become the most commonly used surgical technique for closure of large “planned” ventral hernias with a skin graft during the elective reconstructive phase.11,47,48 Its use for acute definitive closure in the setting of an open abdomen has not been well studied. Formal component separation is generally considered an “elective” reconstructive technique. Its use in the acute setting in the face of resolving intra-abdominal sepsis, visceral, and abdominal wall edema as a result of systemic inflammatory response syndrome and ongoing systemic sepsis is not advisable. Once a formal component separation has been performed, it is eliminated as an option for later abdominal wall reconstruction. There are at least three versions of the component separation technique. The original description by Ramirez et al. is described above. Another surgical technique is the “separation of parts” by the Memphis group. There is also a “open book” technique, which in addition to the lateral release of the external oblique, the rectus fascia (either anterior or posterior) is flipped into the midline using the linea alba as the fulcrum to extend the midline. The rectus roll-over technique by itself has been studied in the setting of definitive closure after the open abdomen in both trauma and general surgery patients. The anterior rectus fascia is incised near its lateral border on both sides, medialized, and sewn in the midline. In a series of 29 patients, the technique was used successfully to close defects up to 15 cm.30 In follow-up of 65 months, no recurrent abdominal wall hernias were noted, although mid-abdominal bulging was noted in 50% of patients. Enteroatmospheric Fistula as a Complication of the Open Abdomen During the initial damage control laparotomy, the open abdomen technique is used for rapid re-entry into the abdomen. DAFC can be commonly achieved once all the intra-abdominal injuries have been addressed. In the setting of intra-abdominal sepsis and/or pancreatitis, DAFC is not as successful.49 It is well recognized that the longer the time period to fascial closure, the higher the complication rates especially intestinal fistulas.50,51 In addition, the obese patient is at increased risk of having more complications after damage control laparotomy and longer time period to primary fascial closure.50,52 Trauma patients who required a prolong period of an open abdomen as part of their damage control management have five times the fistula rate verses those patients who were closed during the initial trauma laparotomy. The enteroatmospheric intestinal fistula results in the setting of the open abdomen. The fistula can develop as a result of an anastomotic leak with exposed suture lines, traumatized bowel, and nontraumatized bowel, which has been exposed for a period of time. This is one of the most devastating complications of the open abdomen. The foremost risk factors are the inability to perform primary abdominal facial closure in a timely manner, and deep space infections, and intra-abdominal abscess.19 The use of polypropylene mesh for bridge repair of the open abdomen has been shown to have unacceptably high rates of fistula complications and is no longer recommended for definitive closure in the acute setting of open abdominal management.34 Fistulae arising during early clinical management of open abdomens result in leakage of intraluminal contents over the unprotected surface of bowel. The patient with an enteroatmospheric fistula has extremely complicated critical care, open abdomen, and nutritional management issues. Inadequate fistula management will result in acute protein calorie malnutrition, electrolyte disturbances, and prolonged hospitalization.53 The key components of management of the patient with an enterocutaneous fistula are as follows: (1) sepsis control, (2) nutritional support, and (3) local wound care (Fig. 2). A key to treating is management of the initial and treatment of resulting control and of sepsis are closure and the on the In patients with intestinal with a or skin management of fistula has been by randomized control not as the of management has the for management of intestinal than 50% of patient with intestinal will require surgery for the control of sepsis and surgical repair for to close or is considered a critical to prevent in an Although, a of the management of intestinal fistula is the of this Table provides additional fistula the open abdomen flow and wound care can be extremely in the patient with an open abdomen and an In an to the inflammatory of the and treated patients with of a and/or skin of this series of closed with only two the of skin graft to the granulated wound can have good results with as as graft at 1 The use of an pressure dressings or the KCI V.A.C. therapy to the to the open abdomen can be a wound management option for wound care is the of the case studies have described techniques for with or without KCI V.A.C. therapy of the wound in attempts to treatment before and after definitive The of at the time of the abdominal wall reconstruction is safe and the treatment for on the of the out in the management the of sepsis, and repair a of 3 to to allow for the development of a management is to the “elective” reconstruction when the sepsis has the inflammatory process the abdominal cavity has the intra-abdominal will through the various of to and resulting in a in the most remain the most a surgeon will Planned Ventral et and other authors are with the initial description of the of damage The of damage control are (1) patient (2) reconstruction of the traumatic injuries with the and (3) being abdominal fascial noted there are multiple techniques to achieve early or DAFC. When this is not the planned ventral hernia technique is Once it has been that the abdominal fascia will not because of massive visceral edema, loss of domain, and/or loss of abdominal wall the only option is a planned ventral hernia or fascial bridge with mesh or The initial of a planned ventral hernia is to the viscera the abdominal This is by using mesh or to prevent This time for the viscera to together. This during the course of 2 to 3 Once the of the open wound has a skin graft can be performed to the the fascial defect is not option is to skin flaps and perform a skin only be when skin flaps in the setting of intra-abdominal sepsis, lack of source control, and massive visceral because this setting has a high risk of skin and In this the wound to to a good granulated and to skin graft tissue coverage may be the of the technique visceral coverage is to decrease and prevent the formation of as a result of trauma from or abdominal closure with or has also been used to the abdominal contents from This is until the viscera have together. The prosthetic mesh is and the is skin have used flaps to the with The is to decrease the of intestinal fistula The of mesh has been used in an to repairs of ventral The data to that the majority of patients with mesh may develop of the repair resulting in a hernia to The of mesh in the process has not been The of damage control is an “elective” abdominal wall of the complexity of this the EAST Open Abdomen Committee is in the process of a of guidelines for abdominal wall reconstruction after the open abdomen. regarding the and postoperative management and follow-up will be (Table Planned Ventral control laparotomy in trauma, emergency general, and vascular in the setting of an laparotomy as a result of has become the of The open abdomen technique has become an component of the The management and closure of the open abdomen has developed into a surgical and remains a to the techniques have been developed to close the open abdomen. The majority of open abdomens can undergo early abdominal fascial closure during the initial re-laparotomy. three or more laparotomies are DAFC can be achieved in the majority of cases using three surgical techniques Wittmann closure with or without the use of a wound When the midline fascia be two other techniques to are bridge closure with mesh or acute component The development of the fistula is a major clinical complication of the open abdomen. The development of the and skin graft of the open abdomen in achieving control of contents and wound when DAFC be one may to ventral with the of abdominal wall reconstruction in the The management of the open abdomen remains a heterogeneous of This is to various such as the of the open abdomen emergency general, and vascular and the of intra-abdominal In addition, there are no for the open abdomen. a of was in 2009 to a for the open The is and can be to there is no of the proposed and it has not been studied or However, a of the open abdomen is a is to be in to this clinical (Table of the